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Your Rights Your Choices Our Uses and Disclosures

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Your Rights Your Choices Our Uses and Disclosures YOUR RIGHTS You have the right to: • Get a copy of your paper or electronic • Get a list of those with whom we’ve medical record shared your information • Correct your paper or electronic • Get a copy of this privacy notice medical record • Choose someone to act for you • Request confidential communication • File a complaint if you believe your • Ask us to limit the information we share privacy rights have been violated See page 2 for more information on these rights and how to exercise them YOUR CHOICES You have some choices in the way that we use and share information as we: • Tell family and friends about your • Provide mental health care condition • Market our services and sell • Provide disaster relief your information • Include you in a hospital directory • Raise funds See page 3 for more information on these choices and how to exercise them OUR USES AND DISCLOSURES We may use and share your information as we: • Treat you • Respond to organ and tissue donation • Run our organization requests • Bill for your services • Work with a medical examiner or funeral director • Help with public health and safety issues • Address workers’ compensation, law enforcement,and other government • Do research requests • Comply with the law • Respond to lawsuits and legal actions See pages 4 for more information on these uses and disclosures 1 Ruby Harbour 817-403-9768 6500 International Parkway, Suite 1000, Plano, TX 75093 Kristian Daniels, VP Compliance and Privacy Officer 972-953-2502 6500 International Parkway, Suite 1000, Plano, Texas 75093 ARLINGTON HEATH MIDLOTHIAN 6201 Matlock Rd. 6435 South FM 549 661 East Main Street Suite 139 Suite 204 Suite 900 Arlington, Texas 76002 Heath, Texas 75032 Midlothian, Texas 76065 817-467-7373 214-501-1410 469-612-5250 BEDFORD IRVING ROWLETT 1305 Airport Fwy. 6161 North State Highway 161 7501 Lakeview Parkway Suites 220 & 130 Suite 200 Suite 130 Bedford, Texas 76021 Irving, Texas 75038 Rowlett, Texas 75088 817-358-5800 972-258-7499 972-463-3100 3501 N. MacArthur Boulevard COPPELL SOUTHLAKE Suite 350A 546 E. Sandy Lake Road 1001 W. Southlake Blvd. Irving, Texas 75062 Suite 210 Southlake, Texas 76092 972-607-2340 Coppell, Texas 75019 817-865-1048 972-258-7426 MANSFIELD 221 Regency Parkway CROSS ROADS Suite 125 8700 US Hwy. 380 Mansfield, Texas 76063 Suite 200 817-477-5884 Cross Roads, Texas 76227 940-365-9400 MCKINNEY 8080 State Hwy. 121 EULESS Suite 300 910 North Main Street McKinney, Texas 75070 Euless, Texas 76039 972-268-9383 817-358-5800 8080 State Hwy. 121 HASLET Suite 240 1205 Avondale Haslet Rd. McKinney, Texas 75070 Suite 100 214-644-5360 Haslet, Texas 76052 817-766-4001 2760 Virginia Parkway Suite 100 McKinney, Texas 75071 972-542-1180 YOUR INFORMATION. YOUR RIGHTS. OUR RESPONSIBILITIES. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. YOUR RIGHTS When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get an electronic or paper copy of your information for six years prior to the date medical record you ask, who we shared it with, and why. • You can ask to see or get an electronic • We will include all the disclosures except or paper copy of your medical record and for those about treatment, payment, and other health information we have about health care operations, and certain other you. Ask us how to do this. disclosures (such as any you asked us to make). We’ll provide one accounting a • We will provide a copy or a summary of year for free but will charge a reasonable, your health information, usually within cost-based fee if you ask for another one 30 days of your request. We may charge a within 12 months. reasonable, cost-based fee. Get a copy of this privacy notice Ask us to correct your medical record You can ask for a paper copy of this notice • You can ask us to correct health at any time, even if you have agreed to information about you that you think is receive the notice electronically. We will incorrect or incomplete. Ask us how to provide you with a paper copy promptly. do this. • We may say “no” to your request, but we’ll Choose someone to act for you tell you why in writing within 60 days. • If you have given someone medical power of attorney or if someone is your legal Request confidential communications guardian, that person can exercise your • You can ask us to contact you in a specific rights and make choices about your health way (for example, home or office phone) information. or to send mail to a different address. • We will make sure the person has this • We will say “yes” to all reasonable requests. authority and can act for you before we Ask us to limit what we use or share take any action. • You can ask us not to use or share File a complaint if you feel your rights certain health information for treatment, are violated payment, or our operations. We are not • You can complain if you feel we have required to agree to your request, and we violated your rights by contacting us using may say “no” if it would affect your care. the information on page 1. • If you pay for a service or health care item • You can file a complaint with the U.S. out-of-pocket in full, you can ask us not Department of Health and Human to share that information for the purpose Services Office for Civil Rights by sending of payment or our operations with your a letter to 200 Independence Avenue, health insurer. We will say “yes” unless a S.W., Washington, D.C. 20201, calling law requires us to share that information. 1-877-696-6775, or visiting www.hhs.gov/ Get a list of those with whom we’ve ocr/privacy/hipaa/complaints/. shared information • We will not retaliate against you for filing • You can ask for a list (accounting) of a complaint. the times we’ve shared your health 2 YOUR CHOICES For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and In these cases we never share your choice to tell us to: information unless you give us written • Share information with your family, close permission: friends, or others involved in your care • Marketing purposes • Share information in a disaster • Sale of your information relief situation • Most sharing of psychotherapy notes. • Include your information in a hospital directory In the case of fundraising: We may contact you for fundraising efforts, If you are not able to tell us your preference, but you can tell us not to contact you again. for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. OUR RESPONSIBILITIES • We are required by law to maintain the privacy and security of your protected health information. • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. • We must follow the duties and privacy practices described in this notice and give you a copy of it. • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html. CHANGES TO THE TERMS OF THIS NOTICE • We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site. • Effective January 1, 2021 • This Notice of Privacy Practices applies to Healthcare Associates of Texas 3 OUR USES AND DISCLOSURES How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you Do research We can use your health information and We can use or share your information for share it with other professionals who are health research. treating you. Comply with the law Example: A doctor treating you for an injury asks another doctor about your overall We will share information about you if state health condition. or federal laws require it, including with the Department of Health and Human Services Run our organization if it wants to see that we’re complying with federal privacy law. We can use and share your health information to run our practice, improve Respond to organ and tissue your care, and contact you when necessary. donation requests Example: We use health information about We can share health information about you you to manage your treatment and services. with organ procurement organizations. Bill for your services Work with a medical examiner or funeral We can use and share your health director information to bill and get payment from We can share health information with health plans or other entities.
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